THE TABLET Newsletter of Division 55 of the American

I stared at the light

blue pad. My face felt

flush, my hand trem-

bled, my heart raced, a

thudding in my chest,

and I began to question

what I'm about to do.

I realized that I held in my hand the power to

heal and the power to harm, even kill. I was

overwhelmed. Thoughts raced through my

head at 100 miles an hour. Seconds felt like

minutes, minutes felt like hours. Then, sud-

denly, information and memories began to

flash in. I realized all the training and prepa-

ration that I have had prepared me for this

moment. Quickly, I was able to assess bene-

fits versus costs, efficacy versus problems,

and delve through the algorithm. Then, with

renewed confidence, my pen moved toward

the pad and the letters began to form "V-y-v-

a-n-s-e.‖ In short order, I had written my

first prescription and begun a wonderful, yet

sometimes scary, new chapter to my career.

I present to you my experiences as a medical

psychologist. What follows are observations

and tales from the trenches, armed only with

my psychological training and a prescription

pad.

In writing that first prescription, flashes of

information streaked across my memory. My

training had prepared me, and prepared me

well. I completed my Post-doctoral Master‘s

Degree in Clinical Psychopharmacology at

Alliant University. Professors included inter-

nal medicine physicians, heads of pharmacol-

ogy programs in medical schools, neuropsy-

chologists, pediatricians, medical psycholo-

gists and a clinical psychologist/biochemist. By

the way, this latter professor had started as a

clinical psychologist and retreaded as a bio-

chemist ―just for fun.‖

The training was phenomenal and poignant. I

enjoyed being taught what I needed to know,

as opposed to so much extraneous informa-

tion, like in college. I would recommend the

training to anyone, regardless of the desire to

prescribe. Quickly, you are struck with the

complexity of the human brain and body, and

how the systems are intertwined and interde-

pendent. Suddenly, you realize that you can

do things that can harm people; however, you

quickly are able to understand the reasons

why and how to deal with them.

Since August 2009, I have written close to

1000 prescriptions without (knocking on my

wooden desk) a problem. Please understand

that this was not without challenges. I quickly

realized how complex the individuals we treat

are, especially at the cellular and receptor

level. For example, one of my patients with

severe depression, anxiety, and grief...

(continued on pg. 8)

RxP: Tales From the Trenches

C. Scott Eckholdt, Ph.D., MSCP

July 2010

THE TABLET: Newsletter of Division 55

of the American Psychological Association

http://www.division55.org/TabletOnline.htm

Editor: Laura E. Holcomb, Ph.D., MSCP

Volume 11, Issue 2

In This Issue:

RxP: Tales From the

Trenches

C. Scott Eckholdt, Ph.D.

1

From the Editor

Laura Holcomb, Ph.D.

2

President’s Column

Owen Nichols, Psy.D.

3

A Psychiatrist’s Per-

spective on RxP

Daniel Carlat, MD

5

Primary Care is the

Key

Pat DeLeon, Ph.D.

11

A Journey Toward

Medical Psychology

Michael Seskin, Ph.D.

14

Prescribing in a State-

Run CMHC

Craig Waggoner, Ph.D.

17

Challenges, Frustra-

tions, and Lessons

Learned as a Neo-

phyte Medical Psy-

chologist

Joseph Sesta, Ph.D.

20

Opportunity and

Responsibility as a

Medical Psychologist

Kelly Ray, Ph.D.

24

Heaven Across the

River

Bob Nevels, Ph.D.

25

Announcement of

Indian Health Service

Program at APA

27

American Society for the

Advancement of

Pharmacotherapy (ASAP)

The Tablet, July 2010

Page 2 THE TABLET: Newsletter of Division 55

I would like to

thank Robin

H e n d e r s o n ,

Doug Marlow,

L y n n e a

Lindsey, David

Wade, Peter Grover, Sandra Fisher,

Lara Smith, Betsy Smith-Jones, Gary

Conklin, Morgan Sammons, Glenn Ally,

Mario Marquez, Elaine Levine, Deborah

Baker, Dan Abrahamson, Suzie Lazaroff,

Pat DeLeon, and Steve Tulkin, some of

the key players in primary or advisory

roles in the passage of Oregon bill

SB1046, which passed 18-11 in the Sen-

ate and then 48-9 in the House, in Feb-

ruary of 2010. Under this bill, psycholo-

gists completing a training program,

agreed upon by a statutorily mandated

task force of 3 psychologists and 3 psy-

chiatrists, would have been able to ob-

tain prescriptive authority. An interdis-

ciplinary committee of 7 members, in-

cluding 4 psychologists, would then have

provided oversight of prescribing psy-

chologists, making recommendations to

both psychological and medical boards.

Unfortunately, Oregon Governor Ted

Kulongoski vetoed the bill, succumbing

to pressure from the opposition. Or-

ganized medicine, the primary opponent

to RxP, has a lot of political and financial

power.

The opposition to RxP may now pro-

claim that the poor, unsuspecting public

in Oregon was saved from a terrible

fate of unleashing inadequately trained

psychologists on them, who would

surely neglect to take into account the

full range of factors that bear on sound

prescribing of psychotropics, and would

risk killing patients by lack of a sophisti-

cated understanding of drug-drug inter-

actions or co-occurring medical condi-

tions. Those of us on the pro-RxP side,

however, would say that the opposition

is woefully lacking in adequate knowl-

edge (or ignoring the available facts) of

the depth and breadth of training re-

ceived by psychologists who prescribe,

and the safe practice of those psycholo-

gists in LA, NM, and the military cur-

rently prescribing. It appears that those

opposing RxP have reasons that have

mostly to do with politics, turf battles,

and fears. Positions on this the type of

issue, which proposes a paradigm shift,

are often based more on emotion than

reason and are, therefore, resistant to

change. But all hope is not lost. After all,

qualified psychologists do safely pre-

scribe in LA and NM. And the struggles

by other non-physician professions

seeking prescription privileges have re-

quired long, hard fights. So, the victory

in the Oregon legislature should be

taken more as a sign of promise that we

are on the right track.

I have recently learned that the promi-

nent psychiatrist, Dan Carlat, MD, is

supportive of appropriately trained psy-

chologists prescribing. Dr. Carlat is Edi-

tor-in-Chief of the well-respected Carlat

P s y c h i a t r y R e p o r t ( h t t p : / /

thecarlatreport.com), a monthly news-

letter on psychopharmacology that is

peer-reviewed and not biased by drug

company funding. I personally subscribe

to this publication, and find it extremely

valuable in informing my consulting

work in psychopharmacology. In the

Car lat Psych iatry B log (http : / /

carlatpsychiatry.blogspot.com/) from

April 11, 2010, Dr. Carlat stated, ―…

we are in a preposterous situation in

which the two major organizations with

expertise on the American mind are

locked in mortal combat: the A.P.A.

( p s y c h i a t r i c ) v s . t h e A . P . A .

(psychological). If they can't figure out

how to resolve differences, God help us

all.‖ It figures that someone who has

valiantly exposed the problems with

drug company sponsored education,

after having been such an educator him-

self, would be the one to have the guts

to speak out about the tension between

psychiatry and psychology, and to sup-

port an issue like RxP, which is so un-

popular among the majority of his

peers. I greatly appreciate that. Dr. Car-

lat was willing to express his views and

ideas in the article, A Psychiatrist’s Per-

spective on RxP, on pg. 5.


From the Editor– Increased Hope After Oregon

Laura E. Holcomb, Ph.D., MSCP [email protected]


Page 3 Volume 11, Issue 2

By now eve-

ryone has

p r o b a b l y

heard that

the Oregon

State Legisla-

ture passed a

bill granting

appropriately trained psychologists‘ pre-

scriptive authority and that this bill was

vetoed by Governor Kulongoski. While

this is certainly disappointing to all of

our membership, it is an unfortunate

part of the process that all the players

must accept. More importantly, psy-

chologists have now successfully

achieved passage of prescriptive author-

ity in four state legislatures and had doz-

ens of bills debated across the country,

as well as achieved significant recogni-

tion as prescribers in many federally

based healthcare delivery systems.

The political process takes a certain

level of mind-numbing tolerance that is

often well beyond the acceptable level

for most rational human beings, but it is

a process that can be mastered. As we

know and appreciate, prescription privi-

leges for psychologists is an extremely

controversial topic for politicians, much

like national healthcare reform. How-

ever, with the determination of a small

group in each state we have seen signifi-

cant advances in the prescription privi-

lege movement, and we must move

President’s Column: One Leg at a Time

Owen T. Nichols, Psy.D., MBA, NHA, ABPP, ABMP

forward and not let one setback distract

us from our efforts to advance this

agenda. We have a significant degree of

opposition from outside forces that are

willing to make hefty financial contribu-

tions, utilize deceptive distortions re-

garding the facts, and make every effort

to create as much drama around the

issue as possible. Unfortunately, there

are also those within our own profes-

sion that are willing to feed into the

misrepresentation of the facts. YET, we

continue to make progress with the

pursuit of prescriptive authority because

there is a need for the expansion of the

scope of our practice into this arena.

The situation in Oregon reminded me

of some of my past conversations and

observations about the political process.

Many years ago, I needed the help of a

powerful political friend and mentor

that I had called upon several times in

the past for assistance. However, this

call was not met with the typical re-

sponse of, ―Sure, let me see what I can

do to help,‖ but rather with, ―Those

folks put their pants on just like you and

me. You go see what you can do and let

me know if you run into a problem.‖

Well, I was initially intimidated by the

idea of getting more involved and push-

ing the system, but it quickly became

clear that anyone can get involved and

the number of serious players is rela-

tively small in most states.

The rumor of Governor Kulongoski‘s

veto decision being related to the influ-

ence of a powerful staff member was

also not surprising, and reminded me of

another conversation. Several years

ago, I spoke with a local politician that

had been defeated and I told him I was

sorry for his loss and that I was sur-

prised that he did not win. He quickly

replied, ―No one was any more sur-

prised than I was.‖ I asked, ―What do

you mean?‖ and he replied, ―After you

are in this business for a while you have

to be careful, because folks around you

start filtering everything you hear, and

everyone close to me was telling me

not to worry, we were going to win.‖ -

- Long-term politicians are sometimes

so isolated by the people around them

that they may not be getting all the in-

formation, and the information may be

so well managed that you never really

reach them with critical information

unless you are seen as part of their in-

ner circle. Unfortunately, the further

up the political food chain one goes, the

tighter the limits on access and the

higher the price of the ticket, unless you

were someone who could be called a

friend and supporter from the begin-

ning.

Not long ago I went to an event in

honor of a colleague where the…




(continued from pg. 3)

… governor showed up unannounced

and spoke. The governor‘s speech was

very telling of the process. While this is

not an exact quote, his remarks went

something like this:

When I decided to run for gov-

ernor, I did not know our friend

that we are here to honor today,

but now I consider him to be an

extremely important figure in

our state that has earned our

respect and admiration. At

first, I was not sure if he was a

supporter or a stalker. When I

was running for governor he

showed up all over the state at

all kinds of functions. After re-

peatedly seeing him and shaking

his hand a dozen or more times,

I started asking my staff to find

out more about this fellow.

They came back with the mes-

sage that if we wanted to know

anything about mental health, he

would be the person to ask. We

finally got around to sitting down

to lunch on the campaign trail

and I realized that he was some-

one that seemed to know what

he was talking about, but even

after lunch, I still wasn‘t sure if

he was a supporter of mine or

not. A few weeks later, he let

me know that he was going to

support me, and he has been a

tremendous supporter, but be-

lieve me I hear about it if he dis-

agrees with me.

Each and every member of Division 55

has a responsibility to be involved and

to take the steps to become more po-

litically active. It took nearly a century

to pass national healthcare reform, and

it has taken other professional groups as

long as 50 years to obtain prescriptive

authority. I have been out of graduate

school for nearly 25 years, and prescrip-

tive authority was beginning to be seri-

ously discussed at that point by the pio-

neers in the area. We must look for-

ward, develop the relationship, make

the financial contributions, learn who is

connected to whom, and above all else

never let a single defeat determine our

destiny as a profession. After all, we

are dealing with folks that put their

pants on just like you and me, one leg at

a time.

Healthcare reform overtime will serve

to level the professional playing field.

We must be prepared to step forward

with the skills and knowledge to serve

our patients, but we must also be active

participants in the process, rather than

blaming others for the outcome of the

process. All too often, members of our

profession fall back on their training and

data to justify why a politician should act

on our behalf, when we have done

nothing to act on their behalf to support

their efforts to hold office. Selfless sac-

rifice may in a few rare instances help

someone win their first election to a

local small town office but rarely will

their career advance to higher office

without the blood, sweat, tears and

cold, hard cash of their supporters.

Dr. Owens is the CEO/President of NorthKey

Community Care in Kentucky.

Owens, President’s Column, Continued

For a PDF of current and back issues of The Tablet

IN COLOR

go to www.division55.org/TabletOnline.htm



Daniel J. Carlat,

MD, is Associate

Clinical Professor

of Psychiatry at

Tufts University

School of Medi-

cine. He has a

private practice

in Newburyport,

Massachusetts.

Dr. Carlat is the

Editor-in-Chief of

The Carlat Psy-

chiatry Report (http://thecarlatreport.com), a

monthly newsletter on psychopharmacology

widely read in the United States, and founder

and president of Clearview Publishing, a CME

provider. In May 2010, Dr. Carlat and Clearview

Publishing released their newest newsletter, The Carlat Child Psychiatry Report.

Dr. Carlat was founder and series editor of the

Practical Guides in Psychiatry series, published

by Lippincott Williams and Wilkins. His text-

book, The Psychiatric Interview, currently in

its second edition, has been translated into four

languages, and is the bestselling book in the

Practical Guide series.

Dr. Carlat’s blog, The Carlat Psychiatry Blog

(http://carlatpsychiatry.blogspot.com/), is consis-

tently ranked as one of the 10 most influential

health blogs by Wikio (www.wikio.com), and has

received an award for outstanding mental health

journalism by the Psych Central website

(www.psychcentral.com). He also blogs for Psy-

chology Today and Psychiatric Times.

Dr. Carlat has been published in the New York

Times, the New York Times Magazine, and

Wired. He is the author of the recently pub-

lished book, Unhinged: The Trouble with

Psychiatry - A Doctor's Revelations about a

Profession in Crisis.

Dr. Carlat is an active member of the American

Psychiatric Association, and is an elected Massa-

chusetts representative on the organization’s

National Assembly.

I am a psychiatrist north of Boston, and

I have been in private practice for 15

years. Looking back on my career path, I

recall that when I was in college, I wa-

A Psychiatrist’s Perspective on RxP

Daniel J. Carlat, MD

vered between medical school and

graduate school in clinical psychology,

but ultimately decided to pursue medi-

cal school, following the advice of my

psychiatrist father. He worked with

many psychologists who were frustrated

with the regulatory limitations on their

practices, and he was concerned I

would share that frustration. I eventually

graduated from medical school at U.C.

San Francisco, and did my psychiatric

residency at Massachusetts General

Hospital.

Over the years, I have followed the RxP

movement with interest. In general, I

support the concept of psychologists

seeking prescriptive privileges. I do not

believe that all four years of medical

school are required for safe and compe-

tent prescribing. I have found that much

of what I learned in medical school has

proven irrelevant to my day-to-day

work as a psychiatrist. It is not as

though I don‘t prescribe drugs fre-

quently—in fact, I have primarily a psy-

chopharmacology practice, with some

supportive and cognitive behavior ther-

apy thrown into the mix. But the skills I

need for prescribing psychotropics util-

ize only a small portion of what I

learned in medical school.

Psychiatry is primarily a psychological

discipline. My work with patients begins

with psychiatric diagnosis, a process that

involves observation, conversation, and

a meeting of the minds. I use the DSM

system to help guide my thinking, al-

though I realize that its limitations are

many. As I evaluate patients, I think in

broad categories of symptomology. Is

this person psychotic? Anxious? De-

pressed? Cognitively impaired? Manic? I

can answer these questions in a prelimi-

nary way very quickly, generally within

the first 5 minutes of an initial interview.

I then use some of the tools of DSM to

help me drill down into specific diagno-

ses by asking about the criteria for vari-

ous disorders.

As you can see, the essence of diagnosis

in psychiatry is psychology. However,

there are medical illnesses that can mas-

querade as psychiatric illness, and I

screen for these as well. The most effi-

cient way to do this is to ask about the

medical history. Does my patient have a

primary care doctor? Does she take any

medications? Has she had any opera-

tions? Has she ever been in the hospital?

Does she feel physically ill in any way

right now? I have most patients sign a

medical release of information so that I

can request recent records from their

PCP.

I used to be more scrupulous about

asking specific questions about the dif-

ferent organ systems of the body, as I

was taught to do in medical school….


http://www.carlatpsychiatry.blogspot.com

http://www.wikio.com/blogs/top/health

http://tinyurl.com/55495f



Called the ―review of systems,‖ this

sequence of questions classically begins

with the head (―Have you had head-

aches? Head injuries? How is your vi-

sion? Etc…) and moves gradually

through the entire body. But over time,

particularly in the context of a middle

class, outpatient, insurance based prac-

tice, I have found that the yield of such

questions is exceedingly low, and now I

ask them only in a focused way. Thus, if

a patient presents with cognitive prob-

lems, I‘ll ask about head injuries and

seizures. If a patient presents with panic

symptoms, I‘ll ask about symptoms of

hyperthyroidism and will likely order a

thyroid stimulating hormone level.

Similarly, although I was taught to do

physical exams in medical school, in

outpatient psychiatric practice I virtually

never do them, aside from the occa-

sional check for symptoms of dystonia

or tardive dyskinesia, both of which may

arise from antipsychotics. Why do I

never to physical exams? Again, because

I have found over the years that the

yield of information relevant to psychi-

atric treatment is vanishingly small. And

as I have gradually forgotten my basic

medical knowledge, I realize that if I

discover a physical finding, I will be un-

able to interpret the meaning of it,

much less treat it, and I will have to

refer patients to their PCP. Thus, it is

much more efficient to get a brief fo-

cused medical history and then to make

sure that the patient gets a full history

and physical from their primary care

doctor, and then to request a copy of

the medical record for my chart.

Once I come up with a provisional diag-

nosis, I begin treatment, either with

medications, psychotherapy, or both.

Prescribing psychotropic meds per se is

not terribly complicated. The compli-

cated part is figuring out if the patient

requires medications, or therapy, or

both. Even more complicated is deter-

mining whether medications are actually

helping, and what to do next when

medications are helping only partially.

Do I increase the dose? Do I add an-

other medication? Do I refer to a thera-

pist?

These thorny follow-up decision points

constitute the bulk of the work of a

typical psychiatrist, and are probably the

best arguments for training integrative

practitioners, whether these are

―prescr ib in g p sycho log is t s ‖ or

―therapizing psychiatrists.‖ Both medica-

tions and psychotherapy have their

place in easing emotional distress, and

the process of combining these tech-

niques requires experience with both.

The default practice style of the modern

psychiatrist is to focus on medication

treatment for a while—often for

months or years—and then to refer to

a therapist if the patient isn‘t getting to

remission. But this is a primitive treat-

ment approach. This bizarrely frag-

mented care would be akin to a pedia-

trician treating an ear infection with

Tylenol for months and then referring

to an infectious disease specialist to give

antibiotics when the earache doesn‘t go

away. This would never happen, because

pediatricians are trained to deploy a

broad range of treatment tools and to

nimbly use them as needed. While they

often refer patients to specialists, they

do so only when they have reached the

limits of their skills and training. Analo-

gously, the properly trained mental

health practitioner should also have a

robust repertoire of skills to draw

upon—which should logically include

both psychopharmacology and psycho-

therapy.

Thus far, what I have written is only

modestly controversial in psychiatric

circles. Some of my colleagues would

quibble with my statement that psycho-

tropics are not ―terribly complicated‖

to prescribe, and would argue that we

do need all four years of medical school

to safely prescribe medications and to

recognize when to refer a patient to a

primary care doctor. Responding to

such arguments is involved, and is not

the purpose of my article.

Ultimately, most psychiatrists would

agree that the ideal mental health practi-

tioner is close to what I have outlined—

that is, a clinician who has expertise in

both meds and therapy. The raging con-

troversy is how we can best produce

Carlat, A Psychiatrist’s Perspective on RxP, Continued



such practitioners. And here, the com-

batants are arrayed against one another

like those along the Maginot line during

World War One. It is the worst kind of

trench warfare, in which the only kind

of communication is the use of weap-

onry—namely money, lobbyists, op-eds,

and an increasingly uncivil discourse on

various list serves and blogs.

My position is that we need to be pre-

pared to give up the idea that there is

something magical about medical school

for the preparation of psychiatrists. Psy-

chiatrists need to realize that we have

done ourselves, and our patients, a dis-

service by insisting that medical school

is necessary for our training. In fact, our

profession is qualitatively different from

the rest of medicine, and we should

create our own interdisciplinary training

programs to teach all the relevant skills

needed to treat our patients.

The pathways to achieving such pro-

grams are many. One option is to start

with current psychiatric training, and to

trim out the irrelevant coursework and

clinical rotations until we arrive at the

ideal program. Another path is to start

with psychology graduate programs, and

beef them up with new coursework in

medicine and psychopharmacology—

similar to the RxP movement. Alterna-

tively, we can simply start from scratch

and create entirely new training pro-

grams.

The mental health work-force shortage

has reached critical proportions. The

option of doing nothing is untenable—

so somebody must do something. To

paraphrase the Jewish scholar Hillel, if

not us, who? And if not now, when?

Carlat, A Psychiatrist’s Perspective on RxP, Continued

Division 55 Board of Directors for 2010

President– Owen Nichols, Psy.D., ABPP, MP, ABPP

President Elect– Glenn Ally, Ph.D.

Past President– Morgan Sammons, Ph.D., ABPP

Secretary– Arlene Giordano, Ph.D.

Treasurer– Mark Skrade, Psy.D.

Members at Large:

Jeff Matranga, Ph.D., ABPP

Earl Sutherland, Ph.D., MSCP

Robert Younger, Ph.D., MP, ABPP

APA Council Reps:

Elaine LeVine, Ph.D., ABMP

Beth Rom-Rymer, Ph.D.

APAGS Representative– Audra Schulman




… appeared to only have one type of

serotonin receptor, the nausea one (5-

HT3). No matter what antidepressant I

gave her, she threw up. But once again,

training persevered. We had to go way

back in the medicine chest, finally

choosing an old tricyclic that agreed

with her system. Now, her mood and

anxiety has improved, and she reports,

―I finally feel like my old self.‖ Was

medicine the only factor? ―Heck, no!‖

There was a lot of psychotherapy ad-

ministered, with developing new coping

skills and ways of handling grief, anxiety,

and stress.

I know. Some of you are going, ―What?

Is he still practicing psychology?‖ Yes,

it‘s true. I continue to be just as good a

psychologist as I was before I could

write a prescription. This part of you

will not die. You will continue to be a

great clinician with an extra tool in your

belt. Your patients will appreciate this.

I have found that our training makes it

much easier to win an alliance and cre-

ate positive progress with both medi-

cines and behavior change. We already

knew that medicines were only a tool

that will assist the person at regaining

functioning. It is at this level where we

continue to help them make significant

attitude and behavioral changes. My

patients appreciate the combination, and

do well with both medicines and thera-

peutic interventions. By the way, many

of my patients just needed good ole

psychotherapy and no medicines. See, I

didn‘t sell my soul to the devil!

Likewise, my physician referrers are just

as pleased. Again, ―Wait . . . What did

he say? . . . Physicians are happy with

psychologists prescribing?‖ Uh, yeah!!!

Many of my friends who are general,

family, and internal medicine physicians

appreciate being able to refer people to

help with the psychological side of their

practice. It is difficult enough to moni-

tor patients for medical needs, much

less psychological problems. Being able

to be referred to a medical psychologist

allows the patient to be dealt with more

holistically, resulting in positive out-

comes. We can deal with the entire

biopsychosocial model, not just the bio

part. In my short time prescribing, phy-

sicians have shown me great trust and a

positive response. In Louisiana, we must

ensure we collaborate with the patient‘s

primary care physician and make them

aware of our treatment plan, including

the medicines and dosages we plan to

use. As of this writing, I have not yet

encountered any resistance or hesitancy

from those collaborating physicians. If I

did, I would simply say, ―Not a problem,

would you be willing to give medicine X

(their preferred medication). I can con-

tinue to treat the patient for other

needs, and monitor the efficacy.‖ You

see how easily it becomes a win-win

situation for all three parties, patient,

psychologist and physician?

Many of you are surely curious about

psychiatry and opposition to psycholo-

gists prescribing. I have always found it

humorous that psychiatry has been up

in arms regarding prescriptive authority

for psychologists, since much of medi-

cine, including psychiatry, has allowed

―everyone else‖ to prescribe, including

nurse practitioners and physician assis-

tants. Ironically, many of the medical

psychologists in Louisiana are partnered

with psychiatrists in joint outpatient

clinics, or work directly with them in

psychiatric units.

The biggest opposition comes from

those in larger metropolitan areas

where there is a greater concentration

of psychiatrists to meet the public‘s

need. However, I am in a more rural

area. It takes 3 months to get in to see a

psychiatric nurse practitioner. You are

not likely to get a psychiatrist appoint-

ment at all, as most do not take new

patients or have a six month waiting list.

Therein lies the problem. In many un-

derserved areas, including state mental

health centers, the need far outweighs

the number of practitioners. This is

true across the nation, and will continue

to be true. Simple logic mandates that if

the population grows, the number of

persons with mental illness will also

increase; therefore, we need more men-

tal health professionals. However, psy-

chiatric medicine has failed to keep

Eckholdt, RxP: Tales From the Trenches, Continued



pace. There simply are not enough

psychiatrists being trained because the

world of insurance and government

make psychiatry the whipping boy for

healthcare cuts. Thus, young physicians

are only doing their one and three

month psychiatry rotations, and getting

out as fast as they can. Fortunately for

me, I have found psychiatric colleagues

that understand the great need and have

been very welcoming, because they

know how many people do not have

access to care.

In the years since Louisiana has passed

its prescription privileges in 2004, I've

had the pleasure to speak to many col-

leagues around the nation that would

also like to pursue prescriptive author-

ity. Unfortunately, it has become clear

that many states continue to make the

errors that we did early on. Two main

hurdles have to be resolved before the

pursuit can begin. One is internal. Ob-

viously, you're going to find that psy-

chologists often do not agree on things.

This is especially the case when a ―hot-

button-topic‖ like prescriptive authority

is discussed. Many states are going to

have psychologists that support pre-

scriptive authority, and then those that

reject this notion. We were no differ-

ent; however, in Louisiana, it became an

opportunity to search for common

ground on this issue. Although many

psychologists were not supportive and

would not choose to obtain prescriptive

authority, their experience with both

general medical practitioners and psy-

chiatrists made it clear that the need

was there. Moreover, it became clear

that psychologists could be trained and

do a wonderful job prescribing.

Sometimes you have to agree to dis-

agree. It's better to admit that one can-

not resolve this difference than to con-

tinue to lose energy trying to win each

other over, as was the the case in our

state. Asking the dissenters simply to

step back and let the others have a shot

is also viable. Many states may not be

able to do this, especially those that

have fiefdoms in major metropolitan

areas spread across the state. For these

states, harder work and more convinc-

ing arguments may be needed. Keep in

mind, our social psychology has always

taught us that a small group that con-

stantly bombards the larger group with

a consistent, concise, clear message can

eventually create attitude change.

The other great obstacle, and probably

the more difficult one, is getting psy-

chologists to leave the confines of aca-

demia and clinical practice and learn a

new game, the GAME of politics. This

game doesn't have clear rules, clear

sides, or clear processes. In fact, the

game of politics may best be described

as the hardest contest you will wage,

because you don't know how to do it,

what to do, or who to do it with. It is

difficult for many psychologists to get

involved in these murky waters; how-

ever, to be successful, one must dive in

headfirst.

In the game of politics, right does not

make might. Knowing both sides of the

argument oftentimes gets you nowhere

but in a verbal wrestling match with

your opponent, which often offends

politicians. Psychologists must acqui-

esce to the idea that we don't know

politics, but there are others who do.

Finding good lobbyists who understand

how politics is played in your state is

quintessential to completing this task. A

good lobbyist is worth his or her weight

in gold, because if anyone can assess the

process, rules, and tactics needed, they

can. Effective lobbyists simply know

how to play the game. Each state is

different. Each state plays by its own

rules. A good lobbyist will know these

rules, as well as how to navigate the

waters, avoid the sharks, avoid the

storms on the horizon and, most impor-

tantly, when to forge ahead in an effort

to get this done. This process is by no

means economical. Money must be

spent both on lobbyists and lobbying.

Acquiring the funds necessary by con-

vincing psychologists to contribute is

often the hardest job to do. But, take it

from those in Louisiana, money in poli-

tics is like having an ace up a sleeve or

the biggest trump card. You will spend

money. You will spend big sums of it….






…. But, you will be successful if you do.

Unfortunately, the monetary responsi-

bility often falls on the activists who are

trying to get this done.

Well, I hope that this provides many of

you with some understanding of the life

of a medical psychologist. I hope not

to offend, but if my ranting pushes oth-

ers forward, I am willing to accept criti-

cism and venom. Ironically, I was a

dissenter initially because I was working

in the developmental disabilities field,

the most overmedicated population on

the earth. Now, I am the one who is

preventing overmedication by using less

medication in combination with behavioral

treatment to remedy the situation. Yin

and yang, I suppose.

C. Scott Eckholdt, Ph.D., MSCP is in private

practice in Lafayette, Louisiana at the Center for

Psychiatric Solutions.



Though many of his peers may express

their strong disagreement with Dr. Car-

lat in his support of the RxP issue, and

perhaps may be threatened by some of

his ideas about psychiatry and its future

(expounded upon in his recently pub-

lished book, Unhinged: The Trouble with

Psychiatry - A Doctor's Revelations about a

Profession in Crisis), his highly respected

status appears intact. And, apparently,

there are some other psychiatrists who

agree with his views on RxP. This is

hopeful.

In a Psychiatric Times editorial on April 5,

2010 (http://www.psychiatrictimes.com/

display/article/10168/1548811), Oregon

psychiatrist Jim Phelps, MD, called on

other psychiatrists who oppose RxP to

examine their own possible cognitive

errors/biases. He asks, ―How can we be

certain that an argument against these

privileges is appealing because of its

logic, and not, instead, because it reso-

nates with an underlying bias in favor of

maintaining a beneficial status quo?‖

Holcomb, From the Editor, Continued

Phelps also argues that when assessing

the risk of psychologists prescribing, the

relative risk should be compared to

those doing the bulk of the prescribing

of psychotropics, primary care provid-

ers, rather than to psychiatrists. Those

familiar with the depth and breadth of

RxP training, and the practices of psy-

chologists prescribing in LA and NM,

argue that psychologists with RxP train-

ing are no more at risk of harming pa-

tients than are psychiatrists. It could be

argued that psychologists with RxP

training who prescribe may be at less

risk of harming patients than many psy-

chiatrists, if you consider that the ma-

jority of psychologists who prescribe

will spend more time with patients, will

see patients more frequently, and will

likely have a better understanding of the

appropriateness of psychotherapy vs.

meds vs. both, leading to better, more

comprehensive care. They may also be

less likely to rely solely on information

provided by drug companies and to seek

out unbiased research, given their ex-

tensive education in research methods

and evaluation. But there is a practical

point in the idea that even IF psycholo-

gists with RxP training were only as safe

in prescribing psychotropics as a PCP, it

would be worth allowing them to pre-

scribe in order to help with the access

problem.

Those in organized medicine are not the

only group to have strongly opposed

RxP. There are a small minority of psy-

chologists who have also strongly spo-

ken out against the movement. Perhaps

they may believe that if psychologists in

their state are given the opportunity to

prescribe, they will be pressured to

follow this path as well. Just as is the

case with neuropsychologists or foren-

sic psychologists, who receive additional

training to specialize in these areas, al-

lowing for those with additional training

in RxP to specialize in practice in that

area by prescribing will not force all

psychologists to take this path but will

be an option for those who are inter-

ested. Perhaps psychologists opposing…




P r e s i d e n t

Obama’s Health

Care Reform

Legislation

If I were to focus

for psychology

upon one aspect

of President Obama‘s Health Care Re-

form legislation, the Patient Protection

and Affordable Care Act (PPACA), P.L.

111-148, I would stress the importance

of becoming involved in providing Pri-

mary Care and in so doing, embracing

the changes that advances in the com-

munications and technology fields will

undoubtedly bring to our daily profes-

sional lives. PPACA includes numerous

provisions intended to increase the pri-

mary care and public health workforce,

promote preventive services, and de-

velop a national prevention and health

promotion strategy including encourag-

ing individuals to adopt healthier life-

styles. It establishes a Preventive and

Public Health Fund to increase support

for prevention and public health, in-

creases access to clinical preventive

services under Medicare and Medicaid,

and promotes healthier communities. A

high priority is also provided for manag-

ing chronic illnesses across settings.

The time has come for psychology to

affirmatively ensure that the critical psy-

chosocial-cultural-economic gradient of

quality care, which APA‘s Norm Ander-

Primary Care is the Key

by Pat DeLeon, Ph.D., JD, ABPP

son has long heralded, is finally valued

by society and its health care leaders.

The changes to our nation‘s health care

delivery system envisioned by those

crafting PPACA will ultimately require

significant changes for all of the health

professions training programs, including

instituting an appreciation for interdisci-

plinary and cross-disciplinary care. One

section of the act would require the

Secretary to establish a demonstration

program to provide recently qualified

nurse practitioners with 12 months of

training for careers as primary care pro-

viders in federally qualified community

health centers and nurse managed

health centers. Another section creates

a new Nurse-Managed Health Clinic

initiative and requires the Secretary to

establish a grant program to fund the

operation of these clinics, which are

providing comprehensive primary health

care and wellness services to vulnerable

or underserved populations. Those

interested in psychology‘s prescriptive

authority (RxP) agenda should readily

appreciate how obtaining this particular

clinical skill will facilitate psychology‘s

emergence into the world of primary

care.

The Views of Visionaries

In November 2008, Senator Max Bau-

cus, Chairman of the Senate Finance

Committee and a major participant in

crafting President Obama‘s legislation,

laid out his vision for health care re-

form. ―The Baucus plan would immedi-

ately refocus our health care system

toward prevention and wellness, rather

than on illness and treatment. Those

who are uninsured – and therefore less

likely to receive preventive care and

treatment for major conditions – would

be given a ‗RightChoices‘ card that guar-

antees access to recommended preven-

tive care, including services like a health

risk assessment, physical exam, immuni-

zations, and age and gender-appropriate

cancer screenings recommended by the

U.S. Preventive Services Task Force….

The plan strengthens the role of pri-

mary care and chronic care manage-

ment. Primary care is the keystone of a

high-performing health care system.

Increasing the supply and availability of

primary care practitioners by improving

the value placed on their work is a nec-

essary step toward meaningful reform.

The plan would refocus payment incen-

tives toward quality and value. Today‘s

payment systems reward providers for

delivering more care rather than better

care. A redefined health system would

realign payment incentives toward im-

proving the quality of care delivered to

patients…. (T)he Baucus plan would

improve the health care infrastructure

by investing in new comparative effec-

tiveness research and health…





… Information Technology (IT). Health

IT is needed for quality reporting and

improvement and to give providers

ready access to better evidence and

other clinical decision-support tools.

Reinvesting in the training of a twenty-

first century health care workforce is

necessary for many delivery system re-

form goals to be realized.‖

In March 2010, at the outstanding State

Leadership conference, The Power of

Advocacy, Katherine Nordal described

her vision for the future of our profes-

sion:

In my keynote speech last year, I

spoke about challenges and op-

portunities for psychology prac-

tice in the context of our expen-

sive and badly broken health care

system. Many of us came to this

conference last year excited

about the possibilities for bring-

ing substantial reform to our

health care delivery system. One

year later, the course of health

care reform is unclear. But what

does remain clear is that the

system ultimately will have to be

changed. We need an integrated

health care delivery system, and

psychologists must be part of the

health care teams in that system.

We cannot afford to watch from

a distance as a new health care

delivery system is crafted… one

that is unlikely to value what

psychologists can bring to the

table if we sit on the sidelines.

When we fail to become in-

volved in advocacy, we give oth-

ers the power over our future as

health care providers…. We

also need to help more of our

members become comfortable

with and accustomed to using

the electronic media that in-

creasingly shape our interactions

with others.

In May 2010, Norm Anderson high-

lighted a number of psychology‘s accom-

plishments during the Congressional

deliberations on the historic health-care

reform legislation, including: ―Integrated

health care: * Inclusion of psychologists

on community-based interdisciplinary,

interprofessional health teams to sup-

port primary-care practices as part of a

new grant program. * Participation of

psychologists as part of health teams or

designated providers of health home

services to provide health care to eligi-

ble individuals with chronic conditions

(including mental disorders) through a

new Medicaid state option…. Psychol-

ogy work force development: * Desig-

nation of a separate $10 million set-

aside for doctoral, postdoctoral and

internship-level training through accred-

ited programs and internships in profes-

sional psychology.‖ This last initiative

was originally envisioned by former APA

President Ron Fox over a decade ago,

and was finally accomplished by the hard

work of APA‘s Nina Levitt of the Educa-

tion Directorate and her colleagues.

The vision and underlying message

should be clear -- professional psychol-

ogy must become active participants in

providing Primary Health Care for

the 21st century.

The Technology of the 21st Cen-

tury

As our nation‘s reimbursement systems

focus increasingly upon demonstrable

outcomes and as all Americans finally

have access to health insurance cover-

age, Tele-health or Tele-psychology will

provide our practitioners with a critical

vehicle to overcome geographical and

systems boundaries, as it will for every

other health discipline. Ken Drude re-

ports: ―The April midyear meeting of

the Association of State and Provincial

Psychology Boards (ASPPB) in Seattle,

Washington, titled Psychology Unpluged:

How Technology Impacts Regulation, fo-

cused on tele-psychology, distance

learning, and distance supervision. Tele-

psychology and tele-health practices,

guidelines, and regulation were major

topics of presentations and discussion.

Interjurisdictional practice implications

and the need for licensing boards to

work together to develop ways to regu-

late tele-psychology practices were

highlighted by presenters. Attendees

DeLeon, Primary Care is the Key, Continued



included representatives from Canadian

and U.S. psychology licensing boards,

the Canadian Psychological Association,

and the APA.‖ Stephen Behnke, APA

Ethics Office: ―Tele-psychology prom-

ises to extend the reach of psychology

to individuals and communities who may

have never received services from a

psychologist. This enormously exciting

and far reaching technological innova-

tion thus represents a significant ad-

vance in how psychology uses technol-

ogy to benefit the individuals and com-

munities with whom psychologists

work. These technological advances

raise legal, ethical, and regulatory ques-

tions that must be carefully considered

and examined to ensure that the good

which comes from psychologists‘ use of

technology outweighs any harms to

consumers. Exploring the clinical, legal,

and ethical aspects of service delivery

will therefore be an essential companion

to psychologists‘ increased use of tele-

psychology.‖

The Front Line

The Care Coordination/Home Tele-

health (CCHT) Program in the Depart-

ment of Veterans Affairs (VHA) cur-

rently provides care to 42,000 Veteran

patients in their homes. CCHT sup-

ports veterans with health-related con-

ditions including diabetes, chronic heart

failure, high blood pressure, and depres-

sion. It is an innovative program that

melds expert care/case management

DeLeon, Primary Care is the Key, Continued

with state-of-the-art health information

technologies. Beginning as a pilot pro-

ject in Florida, South Georgia, and

Puerto Rico in Fiscal Year 2000, its in-

troduction was predicated on using

home tele-health technologies to sup-

port veterans with chronic conditions

and in doing so enable them to avoid

preventable deteriorations in their

health. CCHT achieves this end by pro-

moting veterans‘ ability to self-manage

their chronic condition(s) and obtaining

―just-in-time services‖ through interact-

ing via in-home technology with their

own dedicated VA care coordinator

(nurse or social worker). Positive out-

comes from this pilot for both veterans

and the VA were reduced admissions to

hospital, shorter hospital stays, and very

high levels of patient satisfaction.

In 2003, with the enthusiasm of both

patients and clinicians VA established a

national CCHT program with the ex-

plicit intent of providing the ―right care

in the right place at the right time,‖ and

of offering veterans entering the pro-

gram that, in the management of their

chronic conditions, they would experi-

ence ―no decision about me without

me.‖ Between July 2003 and April 2010,

VA‘s national CCHT has grown from a

program that provide care at any one

time to 2,000 patients from 8 VAMCs

to one that now provides care to

42,000 patients from 153 VAMCs. In

2008, review of routine outcomes data

from a cohort of 17,025 veteran pa-

tients who had received CCHT care

substantiated that the national program

replicated the results of the initial pilot

with a 25% reduction in numbers of bed

days of care, 19% reduction in numbers

of hospital admissions, and a mean satis-

faction score for patients in the pro-

gram of 86%. The cost was $1,600 per

patient per annum, substantially less

than other VA non-institutional care

programs and for commercial nursing

home care placement. VA plans for

further expansion of CCHT include: in-

home support for weight management,

substance abuse, mild traumatic brain

injury, dementia and palliative care to its

portfolio of services, as well as enabling

veterans to use mobile devices (e.g.,

cellular phones) to access care.

For those interested in receiving a first-

hand report on the ongoing participa-

tion of prescribing psychologists in Pri-

mary Care, we would suggest that at

our forthcoming annual convention in

San Diego, division colleagues Elaine

LeVine, Mario Marquez, and Elaine

Orabona Foster would be excellent

mentors.

Pat DeLeon, Ph.D., ABPP is affectionately known

as the Father of RxP. He was President of the

American Psychological Association (APA) in

2000. He won the Division 55 award for Na-

tional Contributions to Psychpharmacology in

2001 and the Division 55 Meritorious Service

Award in 2008.



Although Chi-

nese philoso-

pher Lao-tzu‘s

proverb states,

―A journey of a

thousand miles

begins with a

single step,‖ the

journey is far more interesting when we

can recall that first step. My first step

towards RxP (prescriptive authority for

psychologists) began over dinner with a

friend in San Francisco. He had com-

pleted Alliant University‘s Postdoctoral

Master of Science in Clinical Psy-

chopharmacology Program, and I was

intrigued. Andris Skuja, Ph.D. is a sea-

soned psychologist, master clinician and

generally hardy fellow. We went to

graduate school together, migrated to

our own corners of the world (he to

the Bay area, and me to San Diego) and

for the most part have held similar

views about therapy, politics and life in

general. Andris gave Alliant his stamp of

approval. He reported exciting changes

in his overall clinical orientation as a

result of the training and was particu-

larly enthusiastic about the melding of

psychology and pharmacology. On a

darker note, he warned of the extraor-

dinary exhaustion and stress of main-

taining a full-time practice while simulta-

neously undertaking rigorous clinical

training. Good-naturedly, his wife in-

A Journey Toward Medical Psychology

by Michael R. Seskin, Ph.D.

formed mine ―it almost ruined our mar-

riage.‖ My wife later commented to me

privately that I needed to remember

that I had a family and was no longer

twenty-five. Somehow, despite the fact

that twenty-eight years had passed since

graduation from a doctoral program, I

never considered the possibility that my

brain and body in late midlife might be

substantially different. After all, I was

the guy who attacked graduate school

like a succession of welterweight bouts.

My education in psychopharmacology

began at Alliant University in 2005. The

program was essentially a distance-

learning program accomplished by satel-

lite and spanning a number of campuses

around the country including my home-

town San Diego. The classes were

taught from the San Francisco campus

by a collection of Ph.D.s, M.D.s, and

Pharm.D.s. The overall quality of in-

struction was quite solid and in several

cases exceptional. We were a particu-

larly small contingent in San Diego, a

group that varied from 4-6 members

plus our proctor. For almost 2½ years, I

spent a weekend each month absorbing

human anatomy, biochemistry, neurosci-

ence, pathophysiology, physical assess-

ment, the various organ/biological sys-

tems, and the art and science of psy-

chopharmacology. For the most part

the interactive satellite broadcasts were

technologically reliable, and intellectually

stimulating. The one element the Alliant

program lacked at that time was a

―hands on‖ physical assessment compo-

nent as well as opportunities to actually

train in clinical medicine. Enter Elaine

LeVine Ph.D., pioneering director of the

Southern Institute for the Advancement

of Psychotherapy (SIAP), and visionary

and tireless proponent of RxP.

Toward the end of my studies at Alliant,

Dr. LeVine invited me to attend the

SIAP program in Las Cruces, New Mex-

ico to supplement my study of patho-

physiology and gain hands-on experi-

ence with physical assessment. In 2007, I

traveled monthly to New Mexico to

complete the pathophysiology module,

which consisted of ten courses. Dr.

Levine graciously accepted my Alliant

credits in overlapping areas of study,

and in the summer of 2008 I earned an

Advanced Certificate in Psychopharma-

cology from SIAP (they are currently

granting a Master of Science degree

through the University of Southern

New Mexico). Having always been a

glutton for punishment, this was a glori-

ous educational feast. No regrets—I

would do the same again.

Dr. LeVine‘s program was affiliated with

the Southern New Mexico University

and, most attractively from my stand-

point, many of the pathophysiology and

clinical medicine courses were taught by

the medical staff at Memorial Hospital/



Family Practice Center in Las Cruces.

This hospital houses a top-notch Family

Practice Residency Program and many

of the attendings, residents, as well as

nurse practitioners served as our teach-

ers. I had the privilege of being men-

tored by one of the great champions of

RxP, Lynette Summers, Ph.D., Nurse

Practitioner, and then director of the

Behavioral Health Program at Memorial

Hospital‘s Family Practice Center. The

―hands on‖ physical assessment and

clinical medicine modules are the cen-

terpiece of the SIAP Program. For ex-

ample, each course within the patho-

physiology program was combined with

practicum experience at the Family

Practice Medical Facility where students

examined each other and community

volunteers. After a professional lifetime

of maintaining scrupulous physical

boundaries with patients, a cadre of

twenty-five postgraduate psychologists

donned white coats, mastered the use

of stethoscopes, otoscopes, and blood

pressure cuffs—and, yes—touched each

other. At the conclusion of the ten-

month long pathophysiology sequence

each student produced a compendium

of all the medical cases covered in lec-

ture (mine was 300 pages) and, perhaps

most notably, conducted a full physical

examination (including cranial nerves)

while being observed through a one-way

glass by our preceptors. The passing of

the practicum was mandatory for

graduation. And yes, there were repeat-

ers.

At one point toward the end of my

studies at Alliant University I was simul-

taneously commuting to New Mexico

on a monthly basis to complete the

pathophysiology/physical assessment

module. Without question, this was the

most stressful and rewarding era in my

educational career, perhaps in my life.

During this period my mind was con-

stantly immersed in the vast knowledge

base that constitutes medical science.

Slowly, the biopsychosocial model was

crystallizing its third critical tributary,

basic medical science. In retrospect, this

evolution was not altogether strange or

unfamiliar. As practicing doctoral level

clinical psychologists, we have been

thoroughly schooled in human physiol-

ogy and basic psychopharmacology.

Some of us have sub-specialized in psy-

chological and neuropsychological as-

sessment and for those individuals the

intricacies of human biology, genetics,

and pathophysiology are even more

familiar. In many ways medical psychol-

ogy is a natural extension of clinical psy-

chology, not a professional/educational

non sequitur.

Perhaps the crown jewel of the biopsy-

chosocial model, as envisioned by medi-

cal psychology, is our relationship with

our patients. As a professional group we

spend an enormous amount of time

with our patients and come to know

them as complete, complex individuals.

Each patient‘s unique story is revealed

over the course of weeks, months, and

sometimes years through extended inti-

mate dialogue. In light of this unusually

collaborative relationship, the inclusion

of pharmacological resources into our

practices seems completely natural.

The integration of medical education/

knowledge into my practice has led to

observable changes in the clinical proc-

ess. For example, I currently take a

complete medical history (including all

medications and supplements, not just

psychotropics), carefully observe each

patient‘s overall physical condition (i.e.,

weight, skin tone, gait), review most

recent lab results/medical test findings

(when appropriate), and record blood

pressures and pulse rates when patients

are taking certain psychotropic medica-

tions. Noteworthy, too, is the increased

confidence I experience when talking to

physicians and other medical profession-

als; I feel like a speaker of a foreign lan-

guage who has advanced from basic

conversational skills to an intermediate

level. Lest you think I‘ve forgotten my-

self and now believe I‘m a physician, I do

not.

Over the years of training as a prescrib-

ing psychologist, I‘ve come to admire

clinical medicine as practiced by family

practice doctors, general practitioners,...


Seskin, A Journal Toward Medical Psychology, Continued




… emergency room physicians and

nurse practitioners. These front line

providers simply never know what‘s

coming down the pipeline, and encoun-

ter a full range of diagnostic challenges

and interventional options. For me, such

medical puzzles are exemplified by a

single incident that took place in New

Mexico at an urgent care center where I

was completing an 80-hour physical

assessment and clinical medicine practi-

cum. Under the tutelage of a gifted

nurse practitioner and family practice

physician, I had the good fortune to

examine and diagnose patients under

the watchful eye of my preceptors. The

drill was that I examined and diagnosed

first, presented my findings to the pre-

ceptor and then they repeated the

process. Late one evening after examin-

ing approximately twenty-eight patients,

a 10-year old Native American girl pre-

sented with a rash on her arms and

chest and moderately severe respiratory

distress. After careful deliberation and

perusal of my trusty electronic program

the ―5 Minute Clinical Consult,‖ I felt

smugly secure in my assessment. I sug-

gested to my preceptor that our patient

had a contact dermatitis and an unre-

lated acute asthma attack. After repeat-

ing the history and physical exam the

preceptor smiled and reassured me that

there was no possible way I could have

Seskin, A Journal Toward Medical Psychology, Continued

caught this one. It was indeed a zebra, a

relatively rare condition parading as

something garden variety: nickel poi-

soning. I was flabbergasted. As it turns

out our young patient was wearing a

cherished Native American bracelet that

her favorite uncle had given her. It was

constructed of woven material and fas-

tened with a metal clasp. For three

years she had worn it day and night.

Unfortunately the clasp was nickel and

eventually the metal leeched out of the

clasp into her bloodstream. The medical

presentation, of course, included rash

and respiratory distress. There is abso-

lutely no substitute for front line medi-

cal experience.

After completing the eighty-hour Practi-

cum, I was convinced that I wanted to

absorb as much clinical medicine as pos-

sible. With this goal in mind, I elected to

complete my 400-hour practicum at the

Family Practice Residency Program at

Memorial Hospital where Marlin Hoo-

ver, Ph.D., one of our own, is coordina-

tor of the Behavioral Health Program.

Approximately once per month for the

last 2½ years, I‘ve continued travelling

to Las Cruces to complete the requisite

number of supervised prescribing hours.

Without question, Grand Rounds with

the family practice residents is my favor-

ite training event, one moment consult-

ing on mental health services for a pa-

tient with end-stage liver disease and

the next watching a central line being

placed by a third-year resident. As I

near the end of my practicum, I am cer-

tain that while I will never again observe

a case of nickel poisoning or be called

upon to place a central line, the experi-

ence of being immersed in the world of

clinical medicine has been remarkably

important to my evolution as a medical

psychologist.

While driving to the office this morning

I am aware of a delightful paradox. As I

move toward the end of my career, I

am unquestionably experiencing the

most stimulating, socially relevant, and

just plain cool thing I‘ve ever under-

taken as a practicing psychologist. I

really like—no, love—being an almost

newly minted and credentialed prescrib-

ing psychologist. In Robert Frost‘s

poem, ―Birches,‖ he beseeches a deity

not to snatch him from the earth pre-

maturely. He muses, ―Earth‘s the right

place for love: I don‘t know where it‘s

likely to go better.‖ Like the poet, I

want time to practice as a medical psy-

chologist and witness the burgeoning of

this new specialty. I also feel a sense of

responsibility to champion the RxP plat-

form. Perhaps this is the beginning of my

next thousand miles.

Michael J. Seskin, Ph.D. currently practices in

Del Mar, California with specialties in child/

adolescent psychology, family/marital therapy

and psycho-diagnostic assessment. After com-

pleting the residency in Prescribing Psychology at

the Family Practice Center at Memorial Hospital,

Las Cruces, New Mexico, he plans to divide his

practice between San Diego and New Mexico.


Page 17 Volume 11, Issue 2 Page 17

Prescribing in a State-Run Community Mental Health Center

by Craig D. Waggoner, PhD, MP, ABMP

I am a Medi-

cal Psycholo-

gist (MP),

working in a

S t a t e - r u n

commun it y

m e n t a l

health center

in semi-rural Louisiana. I have been an

MP for 5 years and am a long time

member of the Louisiana Academy of

Medical Psychologists (LAMP). It‘s 8:30

AM, and I lead my first patient (the first

of 14 patients scheduled to see me to-

day) from the waiting room, a 45 year

old female, invite her to sit down in a

chair in my office and ask, ―What can I

do for you today?‖ She has already

seen the nurse, who took her blood

pressure, weight, and glucose level,

asked her what medications other doc-

tors may be giving her, got a urine drug

screen (UDS) and handed off the chart

to me. The results from the nurse tell

me that her BP is normal [good thing

since she is on Effexor (venlafaxine)],

her glucose is elevated, her BMI (Body

Mass Index) is a 32 [bad since she is on

Geodon (Aripiprazole)], and her UDS is

― p o s i t i v e ‖ f o r T H C

(tetrahydrocannabinol, indicating mari-

juana use) and ―benzos.‖

After about 10 minutes of listening to

the patient, I get the basic picture of

what she is telling me and say, ―You say

that you are diagnosed with Bipolar Disor-

der and Borderline Personality Disorder,

you just got out of a 6-day inpatient stay

on a psychiatric unit because you were

suicidal, you are on probation for posses-

sion of marijuana, and what you really

need now is something to help you sleep

better because of the stress of everything

that you have been through lately?‖ What

I haven‘t mentioned yet is that this patient

has no-showed for her last appointment

with me, 4 months ago, and has no-

showed for her therapist‘s appointments

for the last 3 months. She does not have

her own transportation, does not have a

job and is living with her current boy-

friend. We then discuss her sleep prob-

lem, her presenting complaint, all the

while I‘m feeling the influence of her Bor-

derline Personality from her desperate

plea for me to ―fix‖ her problem [and of

course she can tell me exactly what medi-

cine helped her in the past, which was

Restoril (temazepam), a benzodiazepine

hypnotic agent, and she just doesn‘t know

why ―they‖ did not give it to her before

she left the hospital because ―they said

they would‖].

Before letting her go, I take a few minutes

to review the discharge lab results from

her most recent hospitalization. I inform

her of her elevated lipid and glucose lev-

els, and refer her to see her PCP. I con-

duct the 6-month AIMS (Abnormal Invol-

untary Movement Scale). I answer any

questions she might have and ask her to

sign consent forms for the particular

medications I am prescribing, write the

medication prescriptions, and write up a

laboratory order for her to go for a

―Tegretol (carbamezapine) level‖ next

week. I type up a clinical contact note

which documents the details of today‘s

contact, in the State‘s Office of Mental

Health Information System. We then

discuss the reason that I did not (and I

will not) prescribe Restoril for her, and

I review sleep hygiene issues and tell her

to follow up with her clinical therapist

here at the Center to work on this as

well as on other life issues (weight man-

agement, relationships, job, problem

solving strategies, etc.). I recommend

the DBT (Dialectical Behavior Therapy)

group, and refer her for substance

abuse evaluation and treatment. I then

say, ―Ok, our 30 minutes is up,‖ walk

her to the scheduler and tell her I want

to see her back in 4 weeks with a re-

port of her progress. I then take the

next chart from the nurse and start

another patient.

Sounds a lot like what a psychiatrist

might do, doesn‘t it? Here comes the

difference: In the case of this first pa-

tient, I was able to continue her medica-

tions at that visit, even though they are

different from those I was prescribing...




(continued form pg. 17)

… for her before she was re-

hospitalized,. because in Louisiana (and

because I am also a State employee) the

discharging psychiatrist is also the physi-

cian with whom I would collaborate if I

were going to start, stop, or make any

changes to the medication regimen.

Otherwise, according to our prescribing

Statute, I would have to take a few addi-

tional minutes to explain to the patient

that I am a Medical Psychologist, the

circumstances under which I can pre-

scribe her medications, take down a

good telephone number where she can

be reached, and tell her that I will be

contacting her ―within a few days‖ to

discuss with her what I propose to do

with her medications.

The above scenario is not uncommon

and usually will require 30 to 45 min-

utes to accomplish. Fortunately, my

next patient is likely to be an individual

diagnosed with Schizophrenia, Paranoid

Type, who is very stable on his medica-

tion and has been for years, and I can

stay on schedule. In this next case I

quickly review the nurse‘s data, recent

labs (order if not done within last 12

months), conduct the AIMS, rewrite

medication orders for another 6

months, type my contact note, and send

him off to the scheduler to make an-

other appointment in 3, 4, or 6 months,

depending on his need for follow-up

care (i.e. blood levels, lab work up,

checking level of compliance). This con-

tact only required about 15-20 minutes.

I probably end up slightly adjusting the

medications of 20-30% of the patients

that I see, in response to their reports

of symptom changes or side effects. In

these cases, I will collaborate with the

Psychiatrist, as explained above. On

occasion, I will have to taper down and

discontinue an antipsychotic or antide-

pressant and titrate up another one that

has not yet been tried. Because most of

these patients have been taking psycho-

tropic medications for over 10 years,

most monotherapy options have been

tried and polypharmacy is the norm. I

often monitor levels of lithium, valproic

acid and carbamazepine, and watch for

signs of toxicity and/or signs of noncom-

pliance.

Some of the most ill patients still don‘t

believe they even have a mental illness,

and may stop taking all of their medica-

tions at one time. This past week, I had

a patient abruptly stop Depakote ER

(divalproex sodium) 1500mg, Risperdal

(risperidone) 4mg, Zoloft (sertraline)

100mg, and trazadone 100mg. I am in

the process of titrating up her Depa-

kote and Risperdal , and will probably

start titrating up the Zoloft and

trazadone next. I will touch on the

―compliance‖ issue but this will be more

thoroughly handled by her case man-

ager / therap i s t . S im i l ar l y , the

―compliance‖ issue often arises in rela-

tion to patients who will not go to the

laboratory for blood work (e.g. CBC,

BMP, lipid profile, liver profile) at the

recommended intervals, and I am faced

with having to weigh the risk/benefit

ratio of continuing to prescribe the

medicine without having that informa-

tion. Fortunately, and because I am

working in a community mental health

center, I am part of a ―team‖ which al-

ways includes a master‘s level therapist,

peer support specialist, on-site pharma-

cist, and the patient‘s PCP. The team

may also include a Volunteers of Amer-

ica (VOA) case manager, who is often

invaluable in helping the patient keep

their appointments and take their medi-

cations appropriately.

In-between patients I review lab reports

that were recently received and instruct

the nurses about which patients need to

be contacted and sent to their PCP, or

a therapist may come to my office to

request medication refill orders or to

report some change in a patient‘s symp-

toms that needs attention. The above

types of problems are typical of at least

30-40% of the patient population I am

treating. Another 40-50% have a diag-

nosis of schizophrenia or schizoaffective

disorder, 5% have another psychotic

disorder and about 5% have recurrent

and severe depression. And, consistent

with the literature, about 80% have a co

-morbid substance abuse/dependence

disorder. These are truly the ―severely

Waggoner, Prescribing in a State-Run CMHC, Continued



and persistently mentally ill‖ (SPMI) pa-

tients, who need a team‘s support. The

goal of the ―team‖ is to maintain maxi-

mum improvement and minimize re-

hospitalization.

My day goes by at a very fast pace, and

is very challenging but stimulating. Prior

to this, I was working full-time for the

Forensic Division within the Depart-

ment of Health and Hospitals‘ Office of

Mental Health, and was in part-time

private practice. Although I was able to

freely integrate behavioral and pharma-

cologic treatment in my private practice,

my experience was primarily limited to

antidepressants, anxiolytics and hypnot-

ics, and I was looking for an opportunity

for exposure to prescribing a broader

range of psychotropics. My ―break‖

came when the then Medical Director

of the Department of Health and Hospi-

tals emailed several of us MPs, whom

she knew from working with us at our

State jobs, asking if any of us were inter-

ested in helping out prescribing medica-

tions at a MHC in a more rural part of

the state. As it worked out, I was the

only one available to drive the 2 ½

hours to work an 8-hour day, then turn

around and drive back 2 ½ hours to my

home.

I started the job with great apprehen-

sion (feeling somewhat ―under the mi-

croscope― ) but received constant sup-

port and encouragement from my

LAMP colleagues. On the first day, not


even having gone through ―orientation‖

to the State system of prescribing poli-

cies and procedures, the psychiatrist

became ill and went home, leaving me

to prescribe my first antipsychotics and

mood stabilizers, check for drug interac-

tions, and order blood work! I am

happy to say that after making this

weekly trip for 2 years, 2 months, and 2

weeks, with assistance from many oth-

ers within and outside of the State sys-

tem, I was offered, and accepted, a full-

time ―Specialist Prescriber‖ position at

this mental health center. This is the

first such position designated for Medi-

cal Psychologists by the State‘s Civil

Service Commission. When I first

started my one-day-a-week trek, I recall

having a very thick (i.e., 3 inch) ―triage‖

binder of information with me every

time I went, which contained all the

answers to my ―nightmare‖ situations

that I ―knew‖ I would encounter (but

rarely have). It contained information

about all the CYP 450 (Cytochrome

P450) substrates, not only psychotrop-

ics but also many of the drugs com-

monly prescribed by PCPs, potential

drug interactions, ―no-no‖ combina-

tions, cures for overdoses, suggested

algorithms for Bipolar Disorder, Schizo-

phrenia, Depression, and the anxiety

disorders, treatment for side effects,

and the common side-effects for every

psychotropic drug, just to name a few.

As my hands-on experience has in-

creased under the tutelage of two state-

employed psychiatrists and apprehen-

sion has decreased, my ―triage‖ binder

has now been thinned to about a 1 inch

thickness.

One could claim that the many ―anti-

prescribing‖ colleagues, who argue that

we (psychologists), who become able to

prescribe, will simply do ―med checks,‖

were right. I am currently performing

the duties of a typical psychiatrist in a

community mental health center and do

not conduct therapy, per se. There are

at least two other MPs in the State sys-

tem, who do the same. We are helping

to fill the need for providing seriously

mentally ill patients, who might other-

wise have to wait for months to access

care, with access to psychopharmaco-

therapy, and are improving their follow-

up care services. It is no secret that the

Center has been unable to locate con-

sistent psychiatric coverage. In fact, the

current Medical Director flies in from

France for 10 days each month, and

many patients are evaluated via tele-

medicine by the psychiatrist, while in

France, or by another psychiatrist in

New Orleans. Obviously, there is a

need for additional prescribers for the

seriously mentally ill in this and other

parts of the state.

On the other hand, most other MPs in

the state are regularly integrating…





… psychotherapy and pharmacotherapy

in their outpatient practices, something

only a small percentage of psychiatrists,

in my experience, actually do. Filling the

needs of expanding access to pharmaco-

therapy and improving follow up ser-

vices to those needing mental health

services in Louisiana were among the

original goals sought after by the efforts

of LAMP. These goals are being reached

more and more each year.

Dr. Craig Waggoner earned his Master’s of

Science in Clinical Psychopharmacology from

Alliant International University in 2002, prior to

obtaining his license to practice as a Medical

Psychologist in Louisiana in 2005. He is cur-

rently employed with the State of Louisiana, as a

“Specialist Prescriber” at the Lake Charles Men-

tal Health Center in Lake Charles, Louisiana.


LCDR Michael Tilus, Psy.D., MSCP Wins (Another!) Award

the Health Service Category who has

made a significant contribution to the

advancement of health in the United

States, demonstrated leadership in their

work, and shown involvement in health-

related professional or community or-

ganizations or activities. Congratula-

tions, Mike, and thanks for your contin-

ued service!

Our own LCDR Michael Tilus, Psy.D.,

MSCP continues to make us proud. The

Health Services Professional Advisory

Committee (HS PAC) to the Surgeon

General of the U.S. Public Health Ser-

vice (PHS) selected Lieutenant Com-

mander Tilus to receive the 2010 Joseph

Garcia, Jr. Award. This award honors a

junior Commissioned Corp Officer in

Holcomb, From the Editor, Continued


… RxP may believe that if psychologists

begin to focus on psychotropic medica-

tion as a treatment modality, the art of

psychotherapy and the traditions of

psychology will erode. While some psy-

chologists may find themselves in posi-

tions similar to psychiatrists, prescribing

psychotropics without also providing

psychotherapy, many more psycholo-

gists will integrate the two, or at least

will continue to be strong advocates of

psychotherapy when it is the treatment

of choice, or when a combination of

psychotherapy and psychotropic medi-

cation is the best option according to

research. There may also be a very

small group of psychologists who be-

lieve that treatment with psychotropics

is almost never appropriate.

My hope is that the psychologists who

are not interested in pursuit of prescrip-

tion privileges for themselves will at

least not block the efforts of those who

are motivated to benefit patients in this

manner. My hope is that the voices of

psychiatrists like Daniel Carlat, MD and

Jim Phelps, MD will encourage others to

put down their weapons in order to

work together on making use of the

best of both traditions, psychology and

psychiatry, as well as to begin to think

outside the box of either tradition to-

ward new approaches to collaborative

mental health care that are not re-

stricted by turf wars.



October 2009…

Having graduated

and passed the

PEP in 2005, I had

consulted with

primary care phy-

sicians (PCPs)

and advised at-

torneys and the courts on psychophar-

macology for almost half a decade. Yet

there I sat listening to the voice inside

my head (luckily not outside) tell me

again, ―Just go ahead and sign your

name,‖ as I continued to stare at the

first page of my first prescription pad

which now bore my first prescription-

nothing exciting or exotic--Cymbalta, 20

mg q.d. for 1 week, then titrate to 20

mg b.i.d. ―Start low, go slow,‖ said an-

other voice that I recognized as belong-

ing to my old psychopharmacology pro-

fessor (now two voices, but at least not

arguing). Scattered atop my desk were

my ―security blankets,‖ Stahl‘s Pre-

scriber’s Guide and Essential Psychophar-

macology, as well as my Physicians Desk

Reference (PDR) Electronic Library open

on my laptop. I had reviewed the drug‘s

side effect profile, checked and re-

checked, then checked again for phar-

macodynamic and pharmacokinetic drug

-drug interactions with the patient‘s

other medications and over-the-counter

supplements. I had performed a review

of systems, specifically inquiring about

any hepatic or renal impairment, and

had spent 3 hours examining the pa-

tient.

At this pace, my hourly rate was proba-

bly less than the lawn man outside, smil-

ing at me through the window, remind-

ing me of an episode where Dr. House

asked the janitor for medical advice…so

why not a lawn man? ―Hey pal, what do

you think…Selective Serotonin Reup-

take Inhibitor (SSRI) or Selective Nore-

pinephrine Serotonin Reuptake Inhibitor

(SNRI)?‖ Opting to go it on my own

without the lawn man, I signed my

name, faxed in the script to the phar-

macy, and over the next few days

waited for the worst, rarest side effects

I had learned about in class to occur…

but none did. Instead, the patient

showed up next month and felt a little

better, not well, but better, which was a

step in the right direction, both for the

patient and for my fledgling self-

confidence in my prescribing skills. Ok,

so I hadn‘t killed my patient (as Psychia-

try promised). In fact, he was actually

feeling better… onward and upward

with dosing and a few months later, the

patient was reporting no symptoms…

He was well…. and so passed my first

case as an M.P.

During initial weeks of indoctrination

into Medical Psychology, I was often

reminded of A.R. Luria‘s description of

his frontal lobe injured patients, which

he described as having a ‗curious dissocia-

tion between knowing and doing’… some-

thing I would come to understand more

in the forthcoming months as increas-

ingly complex cases presented, and pa-

tients had the audacity not to get well

from my just increasing the dose of

monotherapy to the Food & Drug Ad-

ministration (FDA) maximum recom-

mended level.

Fast forward to present day… Now

with 6 months and about 50 cases un-

der my belt, the count stands at most

patients better, a few well and none the

worse. After practicing Forensic Neu-

ropsychology for 17 years, where the

motto seems to be, ―Know everything,

do nothing‖ (except catch malingerers),

it is extremely rewarding to overcome

the challenges and frustrations of phar-

macotherapy, and watch a patient go

from severe distress, to feeling better,

to actually feeling well (although don‘t

get too used to that last part, as we

often learn to accept silver, not gold).

Some of the major challenges, and often

frustrations, in psychopharmacology

result from a lack of consensus in the

field, such as what do when your patient

hits a plateau at the target dose of

monotherapy, but symptoms are not in

remission? Options?....


Challenges, Frustrations & Lessons Learned as a Neophyte Medical Psychologist

Joseph J. Sesta, Ph.D., M.P.




1. Continue on same drug and titrate

up to the FDA maximum level (or

beyond if you a ―heroic‖ type)

2. Switch to a different drug within the

same class, but with slightly different

pharmacodynamic properties (e.g.,

SSRI to SSRI--Paxil‘s anticholinergic

action vs. Zoloft‘s mild dopamine

reuptake inhibition)

3. Switch to a different drug from a

different class [e.g., SSRI to SNRI/

NDRI (Norepinephrine Dopamine

Reuptake Inhibitor)], but with similar

method of action (e.g., reuptake

inhibition)

4. Switch to a different drug from a

different class, with a different

method of action [e.g., SSRI/SNRI/

NDRI, reuptake inhibition, to NaSSA

(Noradrenergic & Specific Seroton-

ergic Antidepressant), alpha 2 /

5HT2C (Serotonin 2C) antagonism]

5. Combination [e.g., use 2 antidepres-

sants- SSRI + NDRI (―Welloft‖);

SNRI + mirtazapine (―California

Rocket Fuel‖)]

6. Augmentation [SSRI/SNRI/NDRI +

SGA (Second Generation Antipsy-

chotic)/AED (Antiepileptic Drug)/

Lithium (Li)]

Decisions, decisions… lots of options,

but no clear consensus on how to de-

cide. Clinical opinions can vary widely

depending upon whose text/article you

read and/or which drug company is pay-

ing for it. So, slowly and carefully, you

begin to develop your own clinical rules

of thumb through trial and error, hope-

fully because they work most of the

time or, at least, they work more often

than they don‘t work. As for clinical

pearls or words of wisdom for this deci-

sion dilemma, for those working their

way through their first prescription

pad… Every patient is a new treatment

experience-- an experiment of one.

You can try what you have become

comfortable with, but what worked well

for your last few patients may do noth-

ing for your next patient, and may make

the one after that worse… Therein lies

yet another challenge.

Some of my neophyte rules of thumb

are to apply Occam‘s razor to the phar-

macological decision tree and start with

the drug with the simplest pharmacody-

namic method of action (e.g., Lexapro‘s

sole SSRI action). If this does not work,

next ask if there is a single drug with a

secondary method of action that may

help this specific patient‘s residual symp-

tom presentation [e.g., Paxil‘s anticho-

linergic sedation for insomnia/anxiety vs.

Zoloft‘s mild dopamine reuptake inhibi-

tion (DRI) for fatigue, hypersomnia].

Some experts suggest that SSRI drugs

should be ―first line‖ in treating depres-

sion/anxiety, while others believe that

more patients respond to SNRI than

SSRI agents. So, perhaps we should start

with the drug that covers the most bio-

genic amine bases? Should we combine

two antidepressants (AD+AD) before

we augment (AD+SGA/AED/Li)? The

STAR*D studies offer some data in re-

gard to treatment strategies for depres-

sion, and are certainly on the ―must

read‖ list for budding M.P.s Though still

more decisions remain, often less well

addressed by the literature-- when we

need a mood stabilizer do we reach for

an AED (Depakote, Lamictal), an SGA

with classic D2/5HT2A antagonism

(Seroquel, Zyprexa) vs. a partial DA

agonist (Abilify) or do we fall back on

the tried and true—Li—although we

probably understand less about its

method of action than some newer

drugs?

So now you have reached a decision on

a pharmacotherapy strategy for your

patient… Maybe you consulted your

dog-eared copy of Stahl‘s Prescriber’s

Guide and extracted a clinical pearl you

missed the first 100 times your read it;

posted your dilemma on a listserv and

went with the majority opinion; re-read

the Sequenced Treatment Alternatives

to Relieve Depression (STAR*D); called

a friend; asked that smiling lawn man, or

as a last resort uttered ―Lexapro,‖ while

giving the Magic 8-Ball a good shake…

You write your script, and wait for your

next visit to assess the efficacy of your

treatment. However, you don‘t get as

far as the next 30-day follow-up visit

due to one of my favorite challenges—

pharmacoeconomic. Your phone rings

and it‘s your distraught, if not very an-

gry, patient telling you that their co-pay

for that month‘s supply of Geodon you

prescribed to avoid metabolic syndrome

is $400. They make $8.50 per hour at

the local hardware store, and need to

pay their rent or eat instead of paying

for your well thought out drug selec-

Sesta, Challenges, Frustrations, and Lessons Learned…, Continued



tion. Another rule of thumb: No matter

how well crafted your psychopharmacologi-

cal strategy, the efficacy of any drug is nil if

the patient can’t afford to take it… a les-

son learned, but yet another challenge

to meet…prescribing affordably in this

economy.

So now what? Back to the psychophar-

macological drawing board? I found my

patients were fond of handing me the

Wal-Mart/Target $4 drug list (which is

now in PDF form on my desktop), and

saying ―Hey Doc, can you pick one of

these cheap drugs.‖ No, you won‘t find

any of the new and fancy drugs that

match the pens and sticky notes on

your desk, but alas, there are some old-

ies but goodies (fluoxetine) and some

efficacious generics (citalopram, par-

oxetine), along with some oldies but not

so goodies (tricyclic antidepressants--

TCAs) to choose from. Yet another

new challenge arises when you disre-

gard the expensive, non-generic

Lexapro and select the $4 generic

fluoxetine or paroxetine-- The patient

loves you at the pharmacy checkout,

but curses you when 2D6 inhibition

increases the low dose risperidone you

had on board, just in case that family

history of bipolar disorder reared its

ugly head… and now the patient devel-

ops a pharmacokinetic drug-drug inter-

action (DDI).

You address the DDI and realize that

you just learned a valuable pharma-


coeconomic strategy…use a DDI ―side

effect‖ as a cost efficient therapy. Now

when some of my patients cannot afford

even a generic SGA for mood stabiliza-

tion, I select an SGA that is a 2D6 sub-

strate (risperidone) and prescribe a very

low dose of (0.25 mg BID), but when

combined with a potent 2D6 inhibitor

(fluoxetine, paroxetine), it can elevate

to therapeutic level. To make things

even better, Sam from Wal-Mart phar-

macy educated me further… If I pre-

scribe risperidone 0.25 mg BID, 60 tab-

lets are $162/month—too much for my

patient, whereas, if I write for 0.5 mg

tablets to be broken in half and taken

BID, 30 tablets are only $88/month,

which the family could afford. Cheap but

effective pharmacotherapy, another

challenge met (at least for that patient).

My final lesson learned might give some

solace to our psychologist colleagues

who believe M.P.s will simply become

―pill pushers‖ and ignore the bio-psycho

-social model. To the contrary, the

more I treat patients with drugs, the

more I realize that while there are a few

―silver bullet‖ cases where the right

drug finds the right patient and brings

about remission, I can count these cases

on my hands and have fingers left over.

For the vast majority of my cases, which

involve mood and anxiety disorders, the

presenting clinical picture is a complex

mosaic of biological, psychological and

socio-cultural-environmental factors, for

which pharmacotherapy is essentially

triage to attenuate acute symptoms to a

level where the patient and their thera-

pist can begin to appreciate and explore

the totality of the clinical presentation.

Overall, for all the challenges, frustra-

tions, uncertainty, lack of consensus and

penny pinching in psychopharmacology,

I can honestly say that the past 6

months as a practicing Medical Psy-

chologist have been the most challeng-

ing and rewarding in my 17 year profes-

sional career. In closing, I would like to

offer some parting advice ―from the

trenches‖ on some concerns I often

hear from colleagues that are consider-

ing entering Medical Psychology:

Medications can cause side effects

for my patients. Yes they can and most

likely will... so it‘s your job to know

them, explain them and manage them if

(more likely when) they occur.

I could harm or kill someone if

I make a mistake. Yes you can... its

good to never forget that... so be smart,

diligent, thorough, competent and cur-

rent... start low, go slow... never be

afraid to ask for help… put patient care

and safety first and your ego second…

refer out cases that are too complex to

Advanced Practice Medical Psychologists

or to Psychiatrists.





What will I do with all the free drug

company pens? They make great

Christmas and Chanukah gifts!

Dr. Sesta earned a Postdoctoral M.S. in Clinical

Psychopharmacology from Nova Southeastern

University. Dr. Sesta is board certified in Neuro-

psychology (ABN), Pediatric Neuropsychology

(ABPdN) and Medical Psychology (ABMP) with

Added Qualifications in Forensic Neuropsychol-

ogy (ABN). He is licensed as a Medical Psy-

chologist by the Louisiana State Board of Medi-

cal Examiners and as a Psychologist by the Flor-

ida Board of Psychology. Dr. Sesta currently

practices at The Psychology Clinic of Lake

Charles and holds clinical privileges in Medicine

at Women & Children’s Hospital.


Opportunity and Responsibility as a Medical Psychologist

by Kelly P. Ray, Ph.D., MP

I provide con-

tract services

for organiza-

tions, and have

a part-time pri-

vate practice,

one to two days

a week, where I treat both adults and

children. Prescribing is one aspect of

my practice.

I‘ve been surprised by how my thinking

about treatment has changed since I‘ve

been able to prescribe. I guess it‘s simi-

lar to a systems approach, if I had to

describe it. I look at how multiple vari-

ables interact and affect my patients, and

therapeutic efforts focus on adjusting

the variables accordingly. For example,

when working with a patient, I consider

not just the symptoms of the patient,

but also familial and environmental influ-

ences on the symptom exacerbation for

that patient. This is particularly true

with the children. Instead of immedi-

ately adjusting the medications, other

factors are considered prior to deter-

mining whether a medication adjust-

ment is needed. Having the psychologi-

cal training allows me to utilize all areas

of my expertise, not just manage the

medications.

I‘ve had to reconsider my views on

polypharmacy, especially in children.

Sometimes, multiple medications are

necessary for stability. Because it may

take an extended period of time to get

to an improvement in functioning, the

families have been on board with every

addition. After talking with colleagues,

I‘ve come to realize that some of the

need for polypharmacy is likely due to

seeing patients who are more treatment

resistant, or who have already been

tried on medications without success.

Once word gets out about prescribing,

―harder‖ cases get referred.

I rely heavily on colleagues for support.

One of the great things about Louisiana

is the ―family‖ of psychologists willing to

help and guide prescriptive practice.

Whether in the office, or over the

internet or telephone, consultation with

colleagues has become invaluable. In

addition, the physicians with whom I

collaborate are relieved to know that

our mutual patients are seeking psycho-

logical services. The atmosphere has

been collegial and respectful, with recip-

rocal referrals exchanged.

The last couple of years have taught me

much—about my practice and my pa-

tients. The addition of prescriptive au-

thority to my practice has afforded me

the luxury of treating the whole person

and guiding all aspects of care. Whereas

I used to provide my impressions re-

garding treatment to other providers to

prescribe, and was sometimes frus-

trated with the process, I now largely

determine when and if medications or

changes are needed. With this, the re-

sponsibility has exponentially grown,

and utilizing all services available to me

has become even more important as I

balance that responsibility with treat-

ment goals.

Kelly Ray obtained prescriptive authority in

2008. She has a private practice in Baton

Rouge, Louisiana. She is currently the President-

Elect, and has served as the Public Education

Campaign Coordinator for the Louisiana Psycho-

logical Association for a number of years.



My journey to-

ward the prom-

ised land of pre-

scription privi-

leging began in

1994 when I

saw an adver-

tisement for

psychopharma-

cology training for psychologists in The

Monitor. I‘d thought for years that RxP

had to be part of the future expansion

of practice for psychology, so I ordered

the 16 hour CEU take-home exam (PPR

Series One), and flew to Dallas in June

of 1995 for the 18 CEU Series Two

weekend. The first presenter was John

Preston, whose textbook, Handbook of

Clinical Psychopharmacology for Therapists,

now in its 6th Edition, I still use in teach-

ing my Intro to Psychopharmacology

classes.

There were about 250 participants at

the first Series Two weekend. We were

asked to group by state. There were

exactly two of us from Mississippi, El-

dridge Fleming and me, and we became

fast friends and PPR (Prescribing Psy-

chologist‘s Register) roommates over

the course of what turned out to be 26

Series and 465 hours. We took the

Veritas Exam in 1999; I took, and easily

passed, the PEP in 2001, after taking

John Bolter‘s excellent ―PEP Prep‖ 30

hour workshop at CSPP (California

School of Professional Psychology) in

Alameda, in the spring of that year.

Let me insert here that I am a member

of the Louisiana Academy of Medical

Psychologists and thus get to hob-knob

with true heroes of the RxP movement,

like newly elected president, John

Bolter, Jim Quillin, Glenn Ally, Warren

Lowe and a host of others. I do not

belong in such company, but gratefully

bask in their presence when I‘m around

them. Jim Quillin gave me the moniker,

―Mississippi Man.‖ I‘ve changed that re-

cently to ―Stuck in Mississippi Man.‖

Which brings me to the topic about

which I was asked to write —what‘s it

been like to be in a state that has pre-

sented an RxP bill, had a subcommittee

hearing in which we acquitted ourselves

well, but now is making no progress and

actually appears to have regressed to

the Paleolithic consciousness that pre-

vailed before any RxP arguments were

proffered? A little history will help.

In 1997, two years after Eldridge Flem-

ing and I began our PPR training, El-

dridge became president of the Missis-

sippi Psychological Association (MPA).

Also in a fortuitous coincidence, Elaine

Orabona Mantell, one of the ten DOD

PDP (Department of Defense Psy-

chopharmacology Demonstration Pro-

ject) prescribers, was stationed at

Keesler Air Force Base in Biloxi, MS.

The MPA annual convention that year

was held on the Mississippi Gulf Coast

in Biloxi-Gulfport. Elaine gave a great

presentation on her training and prac-

tice as a military prescribing psycholo-

gist. Eldridge and I were less stellar in a

presentation on drug interactions—a

PowerPoint malfunction accounted for

some of this. Nevertheless, RxP was

prominent at the convention and there

were tentative plans to start PPR train-

ing for Mississippi psychologists, in Jack-

son, in the near future.

The PPR training never happened, and

my tenure as co-chair of the nascent

RxP Task Force came to a grinding halt

in 2000, as dissent reigned supreme. Just

prior to that, I‘d tried to get Alliant In-

ternational University to do the training,

which also received no support and had

few takers. I was informed at a meeting

that state associations were giving up on

the RxP agenda and it was nothing more

than a passing fancy. With bravado born

of life-long arrogance, I replied,...


Heaven Across the River: Frustrations and Hopes

of an RxP-Trained Psychologist in a “Fat Chance” State

Next Door to Louisiana

by Bob Nevels, Ph.D., MSCP



(continued from pg.25)

… ―That‘s B-S! You‘ll see the first RxP

state soon.‖ Shortly afterwards, not

surprisingly, the Task Force was discon-

tinued.

In 2004, after attending the APA

(American Psychological Association)

convention in Honolulu and reconnect-

ing with John Bolter, who was honored

by APA for his pioneering efforts in get-

ting RxP passed in Louisiana and writing

the first prescription by a civilian psy-

chologist in the United States, I started

driving to Baton Rouge every three or

so weekends to train with the LA3 co-

hort. Interrupted by Katrina and its af-

termath for several months, the cohort

graduated in June 2007.

In 2005, post New Mexico and Louisi-

ana passing RxP, the MPA RxP Task

Force received an unexpected resur-

rection from MPA‘s then president, Sam

Gontkovsky. Alliant training was recon-

sidered, but it quickly became evident

there was little chance of this eventuat-

ing.

Mostly accidentally and unexpectedly in

2006, with the help of a former state

senator, we had an RxP bill, that was an

exact copy of the then Louisiana law,

dropped in the Public Health and Wel-

fare committee in the House of the Mis-

sissippi legislature. This was a discom-

bobulating experience which alienated

many non-supporters of the agenda

who felt they‘d been betrayed by the

state association. The bill was killed by

Medical within record-breaking time. In

2007, it was reintroduced, and we re-

ceived support from the chair of the

committee and from another energetic

representative, got a subcommittee

hearing and, as mentioned, did well in

answering questions and making a state-

ment for our position. Again, Medical

threatened to ―Make the defeat of this

legislation our number one agenda

item.‖ The bill never was brought up for

a vote in committee. In 2007, MPA

adopted a white paper on RxP that

passed the EC 16 – 0. It was placed on

the website. (Mysteriously, without my

being consulted, it recently has been

taken off the site.) In 2007-2008, APA

gave us a grant, and we hired a lobbyist.

The bill ended up going nowhere, and

the economic meltdown obviated any

future lobbying efforts. We‘re a poor,

small state association. We have no

lobbyist, nor any promise of one on the

horizon. (Not everything from Missis-

sippi is a K-T boundary phenomenon—

Katherine Nordal, head of APA‘s Prac-

tice Directorate, is from here, and is an

avid supporter of RxP.)

Currently, the licensed professional

counselors (LPC‘s) and the marriage

and family therapists (MFT‘s) in Missis-

sippi have lobbyists, and appear to be

unified in efforts to expand their scopes

of practice into full psychological testing

and diagnostic privileges. I‘ve opined in

my rarely read RxP column for The Mis-

sissippi Psychologist that, ―the light at the

end of the tunnel is a freight train.‖ No

one seems to care. Academics, consis-

tent with their non-practice orientation,

uniformly are opposed to the RxP

agenda. Others don‘t see any possibility

for RxP for psychologists in Mississippi

occurring in a reasonable time-frame—

i.e., within their natural life-spans.

I have ―prescribed‖ and ―ordered‖ lab

tests for my patients for 14 years. I call

the M.D. and make my recommenda-

tions for our mutual patients, and they

usually are happy to have the advice. I

then follow with a typed note to be

included in the patient‘s chart. But—it‘s

not the same as the next level. There‘s a

yawning gulf between them. It‘s person-

ally extraordinarily frustrating, some-

times gut-wrenching, to be trapped in

Mississippi while, just 40 miles away

across the Mississippi River, medical

psychologists are writing scripts, giving

nurses orders, ordering labs, practicing,

well,…well, medical psychology.

I still have dreams of awakening across

the river in a practice there before I die.

I‘m running out of time—I‘m 64, and

have avoided the worse consequences

of several medical pathologies that have

been hot on my trail and don‘t give a rip

about my old age hopes and dreams. I

envy Kelly Ray who graduated with me

in the 2007 Alliant class. Kelly is doing

Nevels, Heaven Across the River…, Continued



all those things I mentioned, and has a

long career still ahead of her. Perhaps

John Teal, a young Mississippi psycholo-

gist whose Alliant testing I‘ve been

proctoring, will go on to prescribe in

my stead. However, for a pessimist such

as myself, amazingly, I find I‘m prepared

Nevels, Heaven Across the River…, Continued

to be surprised on the upside.

Bob Nevels is an associate professor at Jackson

State University in the Clinical Psychology Doc-

toral program, where he teaches psychopharma-

cology and other graduate courses. His private

practice is in Ridgeland, Mississippi. He is a

consultant staff psychologist at University of

Mississippi Medical School Hospitals and Clinics.

A Celebration of Psychology

and the Indian Health Service

American Psychological Association Convention Saturday, August 14, 2010 San Diego Marriot

10:00 a.m. to 3:00 p.m.

A unique program describing the ongoing development of Prescribing Medical Psychologist services

on behavioral health teams in the Indian Health Service

The Program Symposium: Speakers on Mental Health in Indian Country, Using the “Talking Circle,” Protecting

Communities Using Tribal and Federal Law, and other topics Hear Rose Weahkee, PhD, Director of Behavioral Health, Indian Health Service; and Melba

Vasquez, PhD, APA President-elect Native American Cultural Festival: Dancing, Drumming, Storytelling, and Grammy award winner,

Michael Brant DeMaria Buffet Luncheon including speaker from the Surgeon General’s Office

Advance Registration Required Cost: $10 Registration Fee covers full buffet luncheon and all CEU programming. We encourage

larger contributions, when possible, to help with conference costs. Register on line at: http://www.alliantconnect.org/donations/fund.asp?id=3733 Or mail your check to Steven Tulkin, PhD, CSPP, One Beach St., San Francisco, CA 94133

Check should be made out to “Native American Health Services Initiative.” For more information email Steven Tulkin [email protected] or Beth Rom-Rymer

[email protected].

Sponsored by Divisions 55 and 18, with support from CSPP at Alliant International University, the

California Psychological Association Foundation, APA Divisions 17, 44, 45, 56, Division V of the

California Psychological Association, the Minnesota Psychological Association, the Florida

Psychological Association and the Indian Health Service

The American Psychological Association

Division Services Office/Div 55

750 First Street NE

Washington DC 20002-4242

Non-profit Org.

US Postage

PAID

Permit No.6348

Washington DC

2010 ASAP Committee Chairs

ABPP


Awards Committee

Morgan Sammons, Ph.D.

Canadian Psychology Committee

Brian Bigelow, Ph.D.

CAPP Liaison

Neal Morris, Ph.D.

Chapter Chairs

Nancy Alford, Psy.D.

Continuing Education Director

Warren Rice, Ph.D.

APA Convention Program of 2010

Massi Wyatt, Psy.D.

Early Career Psychologist

E. Alessandra Strada, Ph.D.

Education and Training Committee

Lenore Walker, Ph.D.

Evidence-Based Research Committee


Federal Advocacy Coordinator

Gilbert Sanders, Ph.D.

Fellows Committee

Vacant

Gerontology Psychopharmacology

Committee

Merla Arnold, Ph.D.


International Psychology

Committee

Elizabeth Carll, Ph.D. Brian Bigelow, Ph.D.

Liaison to the Directors of

Professional Affairs

Michael Schwarzchild, Ph.D.

Media

Nina Tocci, Ph.D.

Membership Committee

Massi Wyatt, Psy.D.

Pediatric Population Committee

George Kapalka, Ph.D.

Practice Guidelines Committee

Bob McGrath, Ph.D.

RxP National Task Force

Michael Tilus, Psy.D.

Special Populations Committee

Victor De La Cancela, Ph.D. (ethnic)

Beth Rom-Rymer, PhD. (geriatric)

George Kapalka, Ph.D. (pediatric)

Susan Patchin, Psy.D. (rural)

Elaine Foster, Ph.D. (women)

S.W.A.A.T. Committee

Owen Nichols, Psy.D.

Tablet

Laura Holcomb, Ph.D.

Webmaster & Listserv Monitor

Gordon Herz, Ph.D.

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THE TABLET Newsletter of Division 55 of the American